Radial artery occlusion can occur in 1-10% of cases after transradial catheterization due to thrombosis from endothelial injury after sheath insertion. While usually clinically silent due to dual blood supply, radial artery occlusion prevents future use of the artery for access. The risk of radial artery occlusion can be minimized by using smaller sheaths, avoiding excessive compression during hemostasis, and administering anticoagulants like heparin. Studies show pulse oximetry or pressure guided compression techniques and sheath sizes under 6 French reduce radial artery occlusion rates.

1. Radial Artery Patency After
Transradial Catheterization
Mark A Kotowycz,MD , MBA , FRCPC
Vladimir Dzavik , MD , FRCPC ,FAHA
Presented by Piti Niyomsirivanich , MD.
Cardiovascular Fellowship Maharat nakhonratchasima hospital

2. Introduction
• Transradial Catheterization
– Reduce major bleeding
– More QOL questionaires score
– Earlier ambulation
– Same day hospital discharge after PCI
– Decrease Cost

3. Radial artery occlusion
• 1-10% of cases
• Usually clinically silent due to dual blood supply
• And usually overlooked > 50% doesn’t routinely access
• But once the artery occluded cannot be used as
– access site for the future catheterization
– as an arterial conduit for bypass surgery

4. Pathophysiology
• Thrombotic process
– reduced with anticoagulant
– radial artery thrombus
• (vascular ultrasound , angiography )
• Local endothelial injury after sheath insertion
• Cessation of blood flow
• Tend to occure early after transradial catheterization
50% spontaneous recanalization within 1-3 months

5. Negative effects radial structural and function
• Structure
– 67% intimal tear
– 36% medial dissections immediately
– Small lumen area in repeated more than the 1st time
• Intimal hyperplasia
• Intima-media thickness
• Function
– Decrease response to NTG

6. Negative effects radial structural and
function
• Structure
– 67% intimal tear
– 36% medial dissections immediately
– Small lumen area in repeated more than the 1st time
• Intimal hyperplasia
• Intima-media thickness
• Function
– Decrease response to NTG
 repeated radial access site failure
 reduced graft patency in patient undergoing bypass
surgery with radial artery conduits.

7. Clinical Presentation
Usually Subclinical due to ulnar collateral circulation

8. • efficacy and safety
– transradial versus femoral approach
Radial % Femoral
%
HR 95% CI P
Major Vascular
Access site
Complications
1.4 3.7 0.37 0.27-0.52 < 0.0001
Other Definition of Major Bleeding
TIMI Non-
CABG Major
bleeding
0.5 0.5 1.0 0.53-1.09 1.00
Acuity Non-
CABG Major
bleeding
1.9 4.5 4.5 0.32-0.57 < 0.0001
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
RIVAL Study

11. • efficacy and safety
– transradial versus femoral approach
Radial % Femoral
%
HR 95% CI P
Major Vascular
Access site
Complications
1.4 3.7 0.37 0.27-0.52 < 0.0001
Other Definition of Major Bleeding
TIMI Non-
CABG Major
bleeding
0.5 0.5 1.0 0.53-1.09 1.00
Acuity Non-
CABG Major
bleeding
1.9 4.5 4.5 0.32-0.57 < 0.0001
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
RIVAL Study

12. In summary From RIVAL Study
• no difference in rates of composite
– Death.
– myocardial infarction.
– Stroke.
– major bleeding between access strategies.
• But
– radial access decreased major vascular
complications.
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011

13. Physical examination
• Weak or absent radial pulse.
• But may have a palpable pulse from collateral
ulnar (retrograde filling)
• Thus : Dx of RAO should not depend on
presence or absence pulse.

14. Natural History
71 % improved
20 % diffuse stenosis
60 % partial or complete
recanalization
Long term (3 months)
American Journal of Cardiology
Volume 83, Issue 2 , Pages 180-186, 15 January 1999
N=162 routine Ultrasound at Day 2 after transradial catheterization

15. Natural History
Catheterization and Cardiovascular Diagnosis
Volume 40, Issue 2, pages 156–158, February 1997
N=563 with a normal Allen test evaluate by U/S
RAO 5.3%
No complication
47% spontaneous
recanalization
follow-up (1 months)

16. Assessing Dual Hand Circulation
• Modified Allen Test

17. Assessing Dual Hand Circulation
• Plethysomography and pulse oximetry
(barbeau test)
No single case observed of hand ischemia in 7000 patients

18. Assessing Dual Hand Circulation
• Duplex ultrasounography (most accurate way)

19. Predictors of RAO
• Diameter of the sheath
• Postprocedure compression time
• Presence of anterograde flow during
hemostasis
• Use of anticoagulation

20. Sheath size
• Oversized of Sheath
–  vascular remodeling
– Thrombosis
250 patients
under going PCI
Pretreated
with NO
Journal of the Society for Cardiac Angiography & Interventions [1999, 46(2):173-178]
6F or larger inserted
S-A ratio > 1  RAO 13%
S-A ratio < 1  RAO 4%
(P=0.01)

21. Sheath size
171 patients
under going PCI
6 F Sheath
5 F Sheath
RAO 1.1% in 5F group
RAO 5.9% in 6F group
NAUSICA trial (Ongoing)
patients under
going PCI
Randomized
4F Sheath
6F Sheath
RAO
1-month follow-up
Catheterization and Cardiovascular Interventions
Volume 57, Issue 2, pages 172–176, October 2002
P = 0.08
NCT00815997

22. Predict radial artery size ??
• Associations between radial artery diameter
– BW , Ht. Surface area  weak correlation and
less predictable
J INVASIVE CARDIOL 2013;25(7):353-357

24. Options to minimized the risks of RAO
• 5F system can be used in most patients.
• New Sheathless hydrophillic guiding catheters
– (external diameter of 5F sheath while 6.5F internal
diameter)
• Larger guides with an external diameter of 6F
sheath that have and internal diameter
equivalent to a 7F guide

25. Patent Hemostasis
• Compressible
• But too aggressive compression
–  no flow state  thrombosis
• Predictor of RAO
– Absence of anterograde flow during hemostasis

26. Patent Hemostasis
• Conventional pressure application
– Versus
– PHOPHET trial
• Pulse oxymeter guided (HemoBand)
• (less RAO at 24 hrs) 5% vs 12%,p<0.05)
– RACOMAP trial
• Mean artery pressure guided (TR Band)
• (less RAO) (1.2% vs 12%,p=0.0001)
Catheter Cardiovasc Interv. 2008 Sep 1;72(3):335-40
Enferm Clin. 2009 Jul-Aug;19(4):199-205

27. TR Band

28. Anticoagulation
• Minimize the risk of the RAO
• Based on observational data because of no
RCT.
• Heparin (Current practice 2000-5000 U of
heparin)

29. Anticoagulant
0
10
20
30
40
50
60
70
80
Spaulding et al. (p<0.05)
N=415
Bernad et al. (p = 0.17)
N=465
no anticoagulant
2000 U heparin
5000 U heparin
71%
24%
4.3% 4.9%
2.9%
Cathet Cardiovasc Diagn. 1996 Dec;39(4):365-70.
Am J Cardiol. 2011 Jun 1;107(11):1698-701

30. Date of download:
6/10/2014
Copyright © The American College of Cardiology.
All rights reserved.
Observations From a Transradial Registry: Our Remedies Oft in Ourselves Do Lie⁎
J Am Coll Cardiol Intv. 2012;5(1):44-46. doi:10.1016/j.jcin.2011.10.005
Rates of RAO in Previously Published Studies According to RAO-Avoidance Strategies Used
Early = 7 days post-procedure in Sanmartin et al. study (8); hospital discharge in Rathore et al. study (9); 24 h post-procedure in Pancholy et al. study
(11); 24 to 72 h post-procedure in Cubero et al. study (12); and 4 to 5 h post-procedure in Bernat et al. study (13). Late = 4 to 6 months post-procedure
in Rathore et al. study (9); 4 to 8 weeks in Plante et al. study (10); and 1 month post-procedure in Pancholy et al. study (11). RAO = radial artery
occlusion; UFH = unfractionated heparin.
Figure Legend:
Whether angioplasty was required or not

31. • But Heparin add on Bivalirudin remains
unclear. (need further investigation)

32. Treatment
• Relatively asymptomatic.
• Observation
• Recanalization
– relieve ischemic symptoms
– to save the artery for future procedure
– Anterograde or Retrograde
• Aspiration after wiring

33. Conclusions
• Occurs in 1-10%
• Mechanism : Thrombosis
• Strategies for minimized RAO
– Small Sheaths or Sheathless
– Non occlusive hemostasis
– anticoagulation

34. Thankyou